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SUMMARYPurpose: To conduct pulse oximetry (PO) and elec-

tric pulp test (EPT) on intact frontal teeth in clinicallyhealthy patients aged between 18 and 25 years who do nothave periodontal disease.

Material/Methods: To achieve the aim 1058 teethof 31 patients were studied. The following inclusion crite-ria for the study were set:

1. Age – 18-25 years.2. Clinically healthy patient, who does not have any

systemic diseases, do not take any medicine systematically.3. Intact frontal teeth – without carious lesions, res-

torations or root canal treatment.4. Lack of periodontal disease.Research was conducted with a pulse oximeter

Contec™ - CMS60D and a custom made probe holder.Results: Average values obtained by pulse oximetry

in upper jaw vary between 83% and 85%. In lower jaw –between 82% and 85%. 99% is the maximum and 48% isthe minimum registered value. The average value of themeasurement of all the teeth is 84%.

The average saturation measured on the small fingerof the right hand of the patient is 98%.

The average value of EPT for all teeth is 4 µA. Themaximum measured value is 20 µA, and the minimum - 1mA.

Conclusions:1. Adequate study of the pulp includes two comple-

mentary methods – electric pulp test (evaluation of inner-vation) and pulse oximetry (assessment of pulp microcir-culation).

2. Teeth that are larger in size have larger values ofPO and EPT, which is in direct relation to the size of theirpulp chamber.

3. The total saturation, measured in the little fingerof the right hand is greater than the one of the teeth.

Keywords: Pulse oximetry, dental diagnosis, pulpcondition

EVALUATION OF CONDITION OF THE PULP BYPULSE OXIMETRY

Dimitar Kosturkov1, Tsonko Uzunov2, Raia Grozdanova2, Viktoria Ivancheva3

1) Dentist in private practice2) Department of Conservative Dentistry, Faculty of Dental Medicine, MedicalUniversity of Sofia3) Student VI year, Faculty of Dental Medicine, Medical University of Sofia

Journal of IMAB - Annual Proceeding (Scientific Papers) 2015, vol. 21, issue 4Journal of IMABISSN: 1312-773Xhttp://www.journal-imab-bg.org

INTRODUCTION:Diagnosis of pulp condition is important for creat-

ing an adequate treatment plan and prognosis as well as con-ducting right and successful treatment. As long as the pulpconsists of blood vessels and nerves, tests for evaluation ofthe condition of the pulp can be divided into two groups:

1. Tests for evaluation of the innervation of the tooth.2. Tests for evaluation of the blood circulation.

Conventional tests for pulp sensitivity (temperature,electric and cavity tests) have some disadvantages [1]:

- Because the nerve tissue is very resistant to inflam-matory processes, it can remain reactive even when the sur-rounding tissues degenerate and thus a false positive resultcan be detected with a non-vital pulp [2].

- These tests are often accompanied by unpleasantsensations [3], which can compromise the outcome (subjec-tive test that depends on the type of nervous system of thepatient).

- In the case of mineral dystrophy, trauma or teethwith incompletely formed apex a temporarily reduced sus-ceptibility may occur [4].

- There is subjectivity [5], as these tests are countedon one side of the patient’s response to stimulus and inter-pretation of the dentist on the other.

- Several researches [5, 6, 7, 8] show that the studyof pulp vascularization instead of innervation is much moreappropriate to determine the vitality of the pulp. This canbe achieved by Doppler probe or a Pulse oximeter.

Pulse oximetry (PO) is a noninvasive method whichmeasures the saturation of the blood. It is widely used ingeneral medicine. In the field of dentistry it can be used forevaluation the condition of the tooth pulp.

The method is based on modification of the law ofBouguer-Lambert-Beer (Figure 1), which concerns the ab-sorption of light by the solution according to the concen-tration and optical properties at a given wavelength. It de-pends on the absorption characteristics of the hemoglobinin the red and infrared spectrum. In the red spectrum theoxyhemoglobin absorbs less light than desoxyhemoglobinand vice versa in the infrared spectrum.

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Fig. 1. Schematic representation of the law ofBouguer-Lambert-Beer. I0 - intensity of the transmittedlight, I - intensity of the light that passes, l - thickness ofthe layer through which the light passes, α - concentrationof dissolved substance (hemoglobin).

There are number of studies, which confirm the ben-efits of PO in the diagnosis of the condition of the pulp -Schnettler & Wallace (1991), Mills (1992), Goho (1999) [9- 13]. However, there are studies that reported disappoint-ing and unexpected results [10, 14, 15].

PURPOSE:To conduct pulse oximetry and electric pulp test

(EPT) on intact frontal teeth in clinically healthy patientsaged between 18 and 25 years who do not have periodon-tal disease.

MATERIAL AND METHODS:To achieve the aim 1058 teeth of 31 patients were

studied. The following inclusion criteria for the study wereset:

1. Age – 18-25 years.2. Clinically healthy patient, who does not have any

systemic diseases, do not take any medicine systematically.3. Intact frontal teeth – without carious lesions, res-

torations or root canal treatment.4. Lack of periodontal disease.

Research was conducted with a pulse oximeterContec™ - CMS60D (fig. 2, fig. 3) to all included in thestudy patients. For better adaptation of the diodes and sen-sors to tooth surfaces, a special holder was created.

Fig. 2. Pulse Oximeter device

Fig. 3. Diode and sensor

During the study, the diode and the sensor were po-sitioned parallel to one another on both sides of each tooth.LED is placed at the vestibular side and the sensor - orally.They must be stable in order to obtain an accurate signal(fig. 4).

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Fig. 4. Application of pulse oximetry

An electric pulp test - EPT with “Yonovit” device hasbeen conducted to all teeth examined with pulse oximetry.

The general saturation of each patient was measuredon the little finger of the right hand.

The data was processed statistically by SPSS v 19.01

RESULTS:The following results shown in the graphics below

were obtained from the conducted researches:

Graph. 1. Values of pulse oximetry in upper jaw

Graph. 3. Values of electric pulp test in upper jaw

Graph. 2. Values of pulse oximetry in lower jaw

Graph. 4. Values of electric pulp test in lower jaw

The pulsations of the pulp and periodontal tissueshave different characteristics (fig. 5):

Fig. 5A.

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Fig. 5B.

Fig. 5.5A) A typical signal of the pulse oximeter obtained

from a tooth. Measured saturation - 72%.5B) A typical pulse oximeter signal from periodon-

tal structures. Measured saturation - 94%.

From the survey of the values variations of pulp satu-ration it came out that 99% is the maximum and 48% is theminimum registered value. The average value of the meas-urement of all the teeth is 84%.

The average saturation measured on the small fingerof the right hand of the patient is 98%.

The average value of EPT for all teeth is 4 µA. Themaximum measured value is 20 µA, and the minimum - 1µA.

From the results shown above is apparent that thelarger the teeth are, which have a bigger pulp chamber, thehigher results are obtained for both the PO and the EPT.

1. Ciobanu G, Ion I, Ungureanu L.Testing of pulp vitality by pulsoximetry.International Journal of Medical Den-tistry. 2012 Apr-Jun;2(2):94-98.

2. Radhakrishnan S, Munshi AK,Hegde AM. Pulse oximetry: a diagnos-tic instrument in pulpal vitality testing.J Clin Pediatr Dent. 2003 Winter;26(2)141-145. [PubMed] [CrossRef]

3. Noblett WC, Wilcox LR,Scamman F, Johnson WT, Diaz-ArnoldA. Detection of pulpal circulation invitro by pulse oximetry. J Endod. 1996Jan;22(1):1-5. [PubMed] [CrossRef]

4. Abd-Elmeguid A, Yu DC. DentalPulp Neurophysiology: Part 2. CurrentDiagnostic Tests to Assess Pulp Vital-

DISCUSSION:There has to be sufficient number of mature neurons

in thepulp in order to conduct an effective EPT [5]. Tem-porary and permanent teeth in the early years after theireruption (until 4-5) are not fully innervated by alpha my-elin axons that respond to irritants. These diagnostic meth-ods rely only on the A-delta fibers without having the pul-pal microcirculation measured. This reduced number ofreceptors makes tooth less sensitive to stimuli, and there-fore - larger probability of false results [2]. Traumatizedteeth may not respond correctly to EPT in the first days,even though they have a normal blood circulation. For thisreason, parallel with EPT and thermal tests should be in-troduced and methods for direct assessment of the pulp vas-cularization, such as laser-Doppler flowmetry and pulse oxi-metry [5].

Our results correspond fully to those obtained byother authors who indicate that pulse oximetry can be ap-plied in clinical practice and contradicts few studies show-ing that the method cannot measure the microcirculation ofthe pulp. The reasons for this discrepancy can be sought inthe sensitivity of the used devices, the need for stability ofthe sensor and the diode and the absence of interferencewith other light sources. A possible reason for the failureof some authors can be also the equipment and methodol-ogy used.

CONCLUSIONS:1. Innervation and blood supply of the pulp deter-

mine its condition. Adequate study of the pulp includes twocomplementary methods - EPT (evaluation of innervation)and pulse oximetry (assessment of pulp microcirculation).

2. Teeth that are larger in size have larger values ofPO and EPT, which is in direct relation to the size of theirpulp chamber.

3. The total saturation, measured in the little fingerof the right hand is greater than the one of the teeth.

REFERENCES:ity. J Can Dent Assoc. 2009 Mar;75(2):139-143. [PubMed]

5. Jayashankar DN, Zakirulla M,Sudhakar V, Allahbaksh Meer. Pulseoximetry- Working principles in pulpalvitality testing. IJHSR. 2012 Aug;2(5):118-123.

6. Kahan RS, Gulabivala K, SnookM, Setchell DJ. Evaluation of apulseoximeter and customized probefor pulp vitality testing. J Endod. 1996Mar;22(3):105-9. [PubMed] [CrossRef]

7. Kenneth M. Hargreaves, StephenCohen. Cohen’s pathways of the pulp.10th Ed.; St Louis: Mosby, 2011;pp.1819-2026.

8. Dutta SD, Maria R. Pulse Oxime-

try: A New Tool in Pulpal Vitality Test-ing People’s. Journal of Scientific Re-search. 2013 Jun;6(1);49-52.

9. Calil E, Caldeira CL, Gavini G,Lemos EM. Determination of pulp vi-tality in vivo with pulseoximetry. IntEndod J. 2008 Sep;41(9):741-746.[PubMed] [CrossRef]

10. Pozzobon MH, de Sousa VieiraR, Alves AM, Reyes-Carmona J,Teixeira CS, de Souza BD, et al. As-sessment of pulp blood flow in primaryandpermanent teeth using pulse oxime-try. Dent Traumatol. 2011 Jun; 27(3):184-188. [PubMed] [CrossRef]

11. Vaghela J, Sinha A. Pulse oxi-metry and laser Doppler flowmetry

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fordiagnosis of pulpal vitality. JInterdiscip Dentistry. 2011; 1(1):14-21.[CrossRef]

12. Siddheswaran V, Adyanthaya R,Shivanna V. Pulse Oximetry: A Diag-nostic Instrument in Pulpal VitalityTesting - An in vivo Study. World Jour-

nal of Dentistry. 2011 Jul-Sep;2(3):225-230. [CrossRef]

13. Levin LG. Pulp and Perira-dicular Testing. Pediatr Dent. 2013Mar-Apr;35(2):113-9. [PubMed]

14. Schnettler JM, Wallace JA. Pulseoximetry as a diagnostic tool of pulpal

vitality. J Endod. 1991 Oct;17(10):448-490. [PubMed] [CrossRef]

15. Schmitt JM, Webber RL, WalkerEC. Optical determination of dentalpulp vitality. IEEE Trans Biomed Eng.1991 Apr;(4)38:346-52. [PubMed][CrossRef]

Address for correspondence:D-r Dimitar KosturkovMobile: +359/883 445 441e-mail: D.Kosturkov@gmail.com

Please cite this article as: Kosturkov D, Uzunov T, Grozdanova R, Ivancheva V. Evaluation of condition of the pulp bypulse oximetry. J of IMAB. 2015 Oct-Dec;21(4):1003-1007.DOI: http://dx.doi.org/10.5272/jimab.2015214.1003

Received: 12/10/2015; Published online: 21/12/2015